Fibromyalgia is more difficult to diagnose than myofascial pain. Essentially, fibromyalgia (FM) is a generalized, widespread pain with tenderness to touch that tends to change from day to day in a given patient.
The American College of Rheumatology (ACR) recently noted that the diagnosis of FM is “no longer made just on the number of tender points.”1 The ACR guidelines now state that the number of such sites (tender points) can vary from 0 to 19, which, of course, makes the diagnosis even more difficult (Figure 1).
The pain and tenderness to touch or pressure associated with FM affects not only muscles but also joints and is always involved with significant chronic fatigue, restless sleep, problems with memory or clear thinking. The ACR now suggest testing for cognitive symptoms, fatigue, feeling unrefreshed after sleep using the somatic symptom scale, which rates each symptom on a scale of 0 to 3.
In addition, the ACR notes that “some patients” may have depression or anxiety. However, in my own experience treating hundreds of FM patients, they all have depression and anxiety. Patient also tends to have other chronic conditions, such as irritable bowel syndrome and irritable or overactive bladder, pelvic pain, and quite frequently temporomandibular joint pain.
Fibromyalgia tends to occur following a major physical and/or psychological trauma. It can occur after a significant battle with a viral disease such as flu, after surgery, and particularly, after motor vehicle or other accidents. It is more common in those with significant collagen diseases, such as rheumatoid arthritis, lupus, or ankylosing spondylitis.
Perhaps the most essential element of their fatigue and restless sleep is that the symptoms must last a minimum of 3 months and not be accompanied by any other significant illness other than the collagen diseases already cited. Common features of FM are outlined in Table 1.
Fibromyalgia patients have an extremely poor response to most antidepressant and antianxiety drugs. According to the FDA, there are 3 approved drugs specifically for FM.2 In June 2007, Lyrica (pregabalin) became the first FDA-approved drug for specifically treating fibromyalgia; a year later, in June 2008, Cymbalta (duloxetine hydrochloride) became the second; and in January 2009, Savella (milnacipran HCI) became the third.2 Other agents commonly used off-label include gabapentin, amitriptyline, and cyclobenzaprine.
I have never seen any one or combination of these drugs significantly improve a patient with fibromyalgia. They tend to cause dizziness, unsteadiness, drowsiness with poor sleeping, edema, and weight gain. The most damning evidence for the use of medications for fibromyalgia was a study of more than 8,000 patients treated with amitriptyline, more than 9,000 with duloxetine, and more than 18,000 patients treated with gabapentin. The number of outpatient visits, prescriptions, and hospitalization decreased slightly but the number of emergency visits increased after adding these drugs. The authors concluded that fibromyalgia treatment with 3 of the major drugs used for this condition had “little impact on reducing health care utilization.”3
According to Vincent et al, more than half of patient with fibromyalgia have 5 or more chronic conditions, including chronic degenerative arthritits, depression, migraine, chronic headache, and anxiety.4 In addition, 40% of FM patients were taking 3 or more medications with minimal improvement; 33% were taking commonly prescribed medications for sleep without significant improvement in sleep; 28.7% of patients were taking selective serotonin inhibitors with minimal improvement;and opioids were taken by 22.4% of the patients.4
Images of the brain have shown that patient with FM have larger volume of the hippocampus than healthy controls.5 FM patient also have an increased incidence of atherosclerosis6 and signs of chronic inflammation (mitochondria dysfunction and increase levels of oxidative stress).7 A one-year gluten-free diet showed a small but significant improvement in symptoms in both patients with irritable bowel syndrome and fibromyalgia.8 The multiple symptoms of chronic fatigue syndrome and fibromyalgia strongly resemble those in patients suffering from autoimmune/inflammatory syndrome. It is also suggested that chronic induced inflammation may play a major role in both chronic fatigue syndrome and fibromyalgia.9
Fibromyalgia is said to cause substantial physical and psychological impairment and costs the healthcare system over $25 billion a year.10